The left ventricular assist device was originally designed to be surgically implanted as a bridge to transplantation for patients with chronic end-stage heart failure. On the basis of the REMATCH trial, the US Food and Drug Administration and the US Centers for Medicare & Medicaid Services approved permanent implantation of the left ventricular assist device as a destination therapy in Medicare beneficiaries who are not candidates for heart transplantation. The use of the left ventricular assist device as a destination therapy (...) raises certain ethical challenges. Left ventricular assist devices can prolong the survival of average recipients compared with optimal medical management of chronic end-stage heart failure. However, the overall quality of life can be adversely affected in some recipients because of serious infections, neurologic complications, and device malfunction. Left ventricular assist devices alter end-of-life trajectories. The caregivers of recipients may experience significant burden (e.g., poor physical health, depression, anxiety, and posttraumatic stress disorder) from destination therapy with left ventricular assist devices. There are also social and financial ramifications for recipients and their families. We advocate early utilization of a palliative care approach and outline prerequisite conditions so that consenting for the use of a left ventricular assist device as a destination therapy is a well informed process. These conditions include: (1) direct participation of a multidisciplinary care team, including palliative care specialists, (2) a concise plan of care for anticipated device-related complications, (3) careful surveillance and counseling for caregiver burden, (4) advance-care planning for anticipated end-of-life trajectories and timing of device deactivation, and (5) a plan to address the long-term financial burden on patients, families, and caregivers. Short-term mechanical circulatory devices (e.g. percutaneous cardiopulmonary bypass, percutaneous ventricular assist devices, etc.) can be initiated in emergency situations as a bridge to permanent implantation of ventricular assist devices in chronic end-stage heart failure. In the absence of first-person (patient) consent, presumed consent or surrogate consent should be used cautiously for the initiation of short-term mechanical circulatory devices in emergency situations as a bridge to permanent implantation of left ventricular assist devices. Future clinical studies of destination therapy with left ventricular assist devices should include measures of recipients' quality of end-of-life care and caregivers' burden. (shrink)

SummaryIntense, sustained nursing lengthens inter-birth intervals and is causally linked with low natural fertility. However, in traditional settings, the effects of such nursing on fertility are difficult to disentangle from those of nutrition. Results from an prospective, direct observational study of reproductive function in well-nourished Amele women who nurse intensively and persistently but who also have high fertility are here presented. Endocrine measures show that ovarian activity resumes by median 11·0 months postpartum. Median duration of postpartum amenorrhoea is 11·3 months, (...) time to next conception is 19·0 months, and the inter-birth interval is 28·0 months. Average life time fertility is 6·8. High fertility in Amele women is due both to refractoriness of reproductive function to suckling stimuli, and to maintenance of equivalent age-specific fertility rates across the reproductive life span. (shrink)

Epaminondas the soldier has been much admired. His two great battles rank as masterpieces of the military art. Epaminondas himself perhaps regarded them as his greatest achievements, to judge by his last words as reported by Diodorus . He had been carried from the battlefield of Mantinea with a spear stuck in his chest. The doctors declared that when the spear was removed he would die. After hearing that his own shield was safe and that the Boeotians had won, he (...) ordered that the spear be removed. One of his friends said to him ‘But you die without a son.’ He answered ‘I do, by God, but I leave two daughters, my victory of Leuctra and my victory of Mantinea’, and then he died. Nor were his ‘daughters’ unadmired. By remarkable chance the future Philip II of Macedon was hostage at Thebes at the very time of Epaminondas' pre-eminence and did not fail to learn, as Chaeronea was to show. (shrink)

It is commonly supposed that in the eighth century B.c. there was a ‘population explosion’ in Greece which moved the Greeks to send out colonies. A. J. Graham in the Cambridge Ancient History iii, 3 is typical: ‘The basic active cause of the colonizing movement was overpopulation’; ‘at the very time when the Archaic colonising movement began, in the second half of the eighth century, there was a marked increase in population in Greece’ . The presumed connection between overpopulation and (...) colonisation is not immediately obvious. The evidence for the population explosion is found in the increased number of burials in Attica and the Argolid, but Athens sent out no colony before the very end of the seventh century and Argos probably none at all, certainly none in this period. So special explanations have to be formulated for Athens' and Argos' lack of colonies while their postulated ‘population explosion’ is presumed for Greece as a whole and called in to explain the burst of colonising in the eighth century. The hypothesis is not used for seventh-century colonisation when the number of burials declines. (shrink)

For Hannah Arendt, the promise serves as currency in a world where predictability of outcome in the realm of human action is impossible, where courage is required in order to submit oneself in word and deed in the public realm, and where forgiveness serves as recourse when things go differently than hoped. Each of these points in Arendt's political philosophy is indebted to Immanuel Kant, a thinker who is often characterized as rejecting rhetoric on aesthetic and moral grounds alike. In (...) Kant and the Promise of Rhetoric, Scott Stroud takes up the apparently straightforward but ultimately complicated question of Immanuel Kant's treatment of, and disposition toward, rhetoric.While Kant is typically characterized as... (shrink)

In CQ n.s. 26 . 62–84 I argued that the defeat of Sparta in 371 B.C. was not due to the pursuit of unwise policies towards the other Greek states. Unwise policies there had been. Sparta being by no means superior to Athens in the formulation of foreign policy, but these did not affect the position on the eve of Leuctra when, with Thebes politically isolated, and with some of the Boeotians disaffected, Cieombrotus at the head of a numerically superior (...) Spartan and allied army was poised for the, destruction of Theban power; a triumph of policy it must have seemed. Sparta failed for military reasons. Her army was unequal to the military genius of Epaminondas. (shrink)

From the materialist stance that I find compelling, the metaproblem of consciousness -- explaining why the problem of consciousness seems hard -- is hardly distinct from the 'easy' problem of explaining how the underlying physical/computational system works, and how it gives rise to perceptions of its own functioning. I discuss several confusions that might plausibly arise in that process, and propose that these confusions could create apparent gaps, ontological and epistemic, in materialist accounts of consciousness, thereby making the hard problem (...) hard. Inversely, resolving these confusions may help solve the hard problem. (shrink)